16 Policy
Pharmacy Practice News • April 2021
Reimbursement Matters
Getting in sync with payors on this issue is key
What’s Your White-Bagging Strategy? I
established practices intended to t would be an understatement to line of sight into the origin and handling ensure patient safety.” say that hospital pharmacists are of a drug prior to receipt by the hospital, disgruntled with the concepts of white raising significant concerns and creat- • “White bagging negatively impacts pharmacists’ ability to validate medibagging and mandated restricted drug ing substantial challenges. These actions cation integrity and maintain overdistribution models that commercial pay- pose significant risks to quality of care sight of storage and handling.” ors include in their armamentarium of as providers have inadequate control in drug spending control tools. Some phar- ensuring patient access to high quality • “By sidestepping well-established supply chain procedures, white bagmacists have prohibited white bagging drugs, as well as the appropriate storage ging disrupts efforts to maintain at their facilities and diligently try to and handling of those [medications].” adherence with protocols designed The AMA statement (bit.ly/3rSU91h) avoid restricted drug distribution, perto ensure patient safety, quality, and haps even closing formularies to those added that “these policies simply serve continuity of care.” affected products. Is this developing into to drive more revenue to health insurers a standoff between hospital pharmacists through their pharmacy benefit management and specialty pharmacy lines of It’s All in the Contract and commercial payors? In my December 2020 column, “Ring- business.” Let’s turn our focus to another aspect of ASHP has taken extensive action to white bagging and other restrictive payor ing in the New Payment Year” (bit.ly/ 3vyaOt6), I suggested that payor require- address payer-mandated white bagging strategies that rarely, if ever, are addressed ments will continue to increase. So it will with an advocacy agenda announced in the pharmacy literature: the business be worthwhile to negotiate payments for March 18. The organization stated that: contracting relationships that your facilthe work done by pharmacy. The negotia- • “[It] stands opposed to payer-manity has established with the commercial dated white bagging models that tions could touch on anything from hanpayors, including MA. These annual conjeopardize optimal, safe, and effective tracts have been put into place to provide dling fees for zero-priced (white-bagged) medication use.” drugs (sidebar) to any number of outpathe covered beneficiary (the patient) with tient and ambulatory clinical services. • “Payer-mandated distribution models services that the hospital system offers— that require clinician-administered The assumption is that there is a desire for example: ER visits, inpatient care, drugs to be dispensed exclusively via at the facility for a workable solution that outpatient care including infusion clinthird-party specialty pharmacies are provides some remuneration for its work ics, perhaps ambulatory services, laboraplacing patients at risk and threaten in handling and administrating, as well as tory services, radiology services, and perto compromise organizations’ welladministering, the affected zero-priced haps physical and occupational services, drug products, albeit not the billed etc., depending on contract terms. revenue from the markup on the The covered beneficiary (patient) drug that was lost. has signed up with this carrier for Such involvement also is based their health insurance at what can on the assumption that hospital be a substantial sum. Imagine their pharmacists are willing to continue shock at arranging for services at to be advocates for patient assisyour infusion clinic only to find that tance programs, working with their your pharmacy has denied the use of in-house financial navigators and expensive drugs that their insurance supporting agencies. Another piece carrier is willing to provide as zeroof this puzzle involves negotiating priced (white-bagged) drugs to you. with pharmaceutical companies. They may very well have chosen this Remember that you can negotiate plan because of coverage of those the handling fees for these patientdrugs that you are now blocking. specific zero-priced drugs, because My point is this: Refusing to work there is no billed revenue from with white bagging isn’t a viable hite bagging is the practice of having their use. The functions of receivoption. Whether it is the foremenpatient-specific medications or suping, storing, handling, prepartioned contracting for handling fees plies delivered directly to the practice seting and returning or disposing of for these medications or some othting (outpatient infusion center, physician zero-priced patient-specific drugs er strategy, work with your payors office, hospital) for use by a specific patient. is very similar to those for zeroto come up with a mutually benThe specialty pharmacy shipping the prodpriced white-bagged medications. eficial solution. Also, remember that uct directly to the practice site has already billed the insurance company for the product Many of the frustrations and conthis isn’t a decision that pharmacy and collected the copay from the patient or cerns that hospital pharmacists have should be making unilaterally withsecondary insurer. There is no opportunity for about zero-priced drugs relate to out the endorsement of the C-suite the practice site to bill for the product; it is prethe areas of supply chain, storage, and their disclosure of this decision paid or complimentary. The practice evolved security and vetting of the products. to the health insurance carrier and due to some insurance carriers mandating that These are valid concerns that need all key stakeholders. patients and providers use specialty pharmato be addressed. They’re time-concies to obtain their medications. ManufacturerCollaborative Practice suming and often can go against the supported patient assistance programs and Agreements grain of established departmental some FDA-assigned Risk Evaluation and Mitstandard operating procedures. Payor relationships aren’t the only igation Strategies programs also are cited as In a March 8 white paper, the ones that hinge on effective negotireasons why specialty pharmacies become the AMA addressed the issue by urging ating; collaborative practice agreemandated source for prescription dispensing. regulators to prohibit health insurments also require all stakeholders (Clear bagging, a related process, is the term ance pharmacy policies that “limit to be equally involved and advocatused when the health care system supplies the medications from its own specialty pharmacy.) the ability of hospital staff to have ing for their interests. But for that
What W hat IIs sW White hite Bagging?
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“Reimbursement Matters” is a tool for maintaining your health system’s fiscal health. Please email the author at bonniekirschenbaum@ gmail.com with suggestions on reimbursement issues that you would like to see covered.
Bonnie Kirschenbaum, MS, FASHP, FCSHP
A Reimbursement Lexicon AMA, American Medical Association; CPT, Common Procedural Terminology; E/M, evaluation and management; MA, Medicare Advantage; MLN, Medicare Learning Network; PFS, Physician Fee Schedule
to happen, a basic grasp of how payments are made in this setting is required. Let’s start with the basics: Because collaborative practice agreements establish a formal relationship between the pharmacist and the physician, your first step is to understand the reimbursement structure that governs physician payment. From a Medicare perspective and any commercial plans that follow Medicare’s lead, this is found in the PFS regulations. Some of those commercial plans may be the ones that cover your MA patients. Payment for office and outpatient E/M visits should be a focus. MLN Bulletins are an easy way to stay on top of this, because they provide the key rule-set changes as well as background material and references just as they do for drugs and biologicals. For instance, a recent publication addresses PFS payment of office and outpatient E/M visits (CPT 99201-99215) to illustrate how Medicare generally adopts the new AMA coding, language and interpretive guidance framework (go.cms.gov/3rVj18u; go.cms.gov/2QbfsgB).
Promoting Wellness COVID-19 cases are down, but the pandemic is still with us. Amid those pressures, it’s all too easy for patients and caregivers to forget about wellness. Are you part of the “Annual Wellness Visit” or “Yearly Wellness Visit” that focuses on preventive health? Pharmacists are uniquely qualified to perform a health risk assessment and develop or update a personalized prevention plan for the patients they routinely see while providing or managing their medications. And it’s a reimbursable service! For more information, visit go.cms.gov/3eNTLxs. For details on how to properly provide and bill for Medicare preventive services, visit go.cms.gov/3cyZ9Sg.
Drug Exclusions Finally, a note on yet another oft-overlooked area of reimbursement: keeping up with the latest version of the selfadministered Drug Exclusion list, which took effect April 1, 2021. This is a vital step in ensuring the accuracy of billing and reimbursement. For more guidance, see go.cms.gov/2QfP6u1. ■
